Working together

Make a referral

Tell us about the support you or someone you care for needs. Our team will review your referral and contact you about next steps.

This form is not monitored for emergencies. If someone is in immediate danger, call 000.

Person needing support

First name

Last name

Date of birth (optional)

NDIS number (optional)

NDIS plan start date (optional)

NDIS plan end date (optional)

Parent or guardian

Only if the person needing support has a parent or guardian.

Guardian first name (optional)

Guardian last name (optional)

Contact details

For a child, you can give their parent or guardian’s contact details.

Email address

Mobile phone (optional)

Home phone (optional)

Work phone (optional)

Address (optional)

About the referral

Support or service requested (optional)

Notes or reason for referral

A short summary is enough. Please don’t include Medicare numbers or detailed medical records. Up to 2,000 characters.

About the person submitting

I am referring

Declaration

These details are sent securely to Yellow Balloon Therapy’s practice system for staff to review. They are not sent to the website’s AI assistant. Submitting a referral does not create a client account or confirm an appointment. Contact the practice with questions about your information.

I consent to my information being provided to Yellow Balloon Therapy for the purposes of referral, and service delivery.

Your full name

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Call 0413 970 965 Email the practice